TOA
- 1. PID and TOAMorgan Taylor
- 2. Clinical FeaturesLower abdominal painBilateralRecent onsetWorsens with coitusWorsens with jarring movementsOnset during or shortly after mensesAUB in 1/3 of patientsNew vaginal dischargeFever and chills
- 3. Risk Factors<25yoEarly coitarcheNew, multiple, or symptomatic sexual partnersNonbarrier contraceptionAlso, factors facilitating PID include hx PID, sex during menses, vaginal douching, BV, and IUDs.
- 4. Physical Examination½ have feverDiffuse tenderness, greater in LQsMay or may not be symmetricalRUQ pain may be perihepatitisPurulent endocervical dischargeAcute cervical motion tendernessAdnexal tenderness (sign that correlates best with the finding of endometritis)
- 5. PerihepatitisFitz-Hugh Curtis SyndromeInfection of liver capsule and peritoneal surfacesPatchy purulent and fibrinousexudate in the acute phase that primarily affects anterior surfaces of the liverSudden onset of RUQ pain with pleuritic component sometime referred to right shoulderCan be mistaken for cholecystitisAST/ALT abnormal in ½ of patients
- 6. Diagnostic CriteriaEmpiric therapy for women with abdominal pain and one of the following:Cervical motion or uterine/adnexal tendernessTemp > 38.3Peripheral leukocytosisCervical or vaginal mucopurulent dischargeWBCs on saline microscopy of vaginal secretionsElevated ESRElevated CRP
- 7. Diagnostic Criteria IIPatients with pelvic pain and tenderness and one or more of following are confirmed cases:Endometritis or acute salpingitis on biopsyGC or Chl in genital tractGross salpingitis seen at laparoscopy or laparotomyIsolation of pathogenic bacteria from clean specimen from the upper genital tractInflammatory/purulent pelvic peritoneal fluid w/o another source
- 8. Definitive DiagnosisHistologic evidence of endometritisImaging revealing thickened fluid filled oviductsLaparoscopic abnormalities consistent with PID (tubal erythema, edema, adhesions, purulent exudate or cul-de-sac fluid, abnormal fimbriae)
- 9. TestingLabs:Pregnancy testUACBC (fewer than ½ of PID pts have leukocytosis)Gram stain and microscopic eval of vaginal D/C GC/ChlOccult blood testCRP (optional)
- 10. ImagingTransvaginal USGIn one series of 55 women with definitive PID who underwent TVUSG, the findings of abnormal oviducts, multicystic ovaries, and increased cul-de-sac fluid were 32%, 42%, and 37% sensitive and 97%, 86%, 58% specific.
- 11. Indications for hospitalizationPregnancyLack of response or tolerance to oral medsNonadherenceInability to take meds 2ndary to N/VSevere illness (high fever, N/V, severe pain)Pelvic abscessPossible surgical intervention or diagnostic exploration
- 12. PathogensTwo most important pathogens are Chlamydia Trachomatis and NeisseriagonorrhoeaeShould also have coverage for:A and B streptococciE. Coli, Klebs, ProteusBV flora
- 13. Rec’d RegimensGC becoming more and more resistant to fluoroquinolones.Parenteral1) Cefoxitin or Cefotetan plus Doxycycline2) Clindamycin plus Gentamicin3) Ampicillin-sulbactam plus DoxycyclineDoxycycline causes pain when infused intravenously so PO administration is recommended.
- 14. Rec’d RegimensOral therapy1) Ceftriaxone IM plus Doxycyclinew/ or w/o Metronidazole2) Cefoxitin IM with Probenecid plus Doxycyclinew/ or w/o Metronidazole3) 3G Cephalosporin IM like Cefotaxime or Ceftizoxime plus Doxycyclinew/ or w/o MetronidazoleMetro added for pelvic abscess, suspected Trichomonas or BV, hx of gynecologic instrumentation
- 15. Duration of treatmentOptimal duration unknown but most studies used 14 days and CDC guidelines use this.If outpatient therapy selected, must F/U within first 48-72hrs to ascertain clinical improvement.
- 16. TOAEpidemiology TOA occurs in up to 1/3 of patients. Estimated 100,000 cases per year Most commonly in women 20-40yo Previous PID not more common in TOA pts Does not appear to be increased risk with newer IUD devices …no clear risk factors for TOA in PID
- 17. DiagnosisTOA should be suspected in any PID patient.Absence of fever and/or leukocytosis is not an argument against TOA (60-80% have).Abdominal findings of ileus may be more common in PID patients with TOA.Unclear whether pelvic examination helpsOne study showed 90% were clinically appreciatedUnsuspected TOA seen with high frequency when laparotomy performed for failure of medical therapy.
- 18. USGTest of choice to R/O TOA.One study, TVUSG identified 32 of 33 surgically confirmed TOAs, and ruled out 33 of 34 patients.Appears as one or more homogeneous, somewhat symmetrical, cystic, thin-walled, well-demarcated mass(es) which are usually contiguous. Septations and AFLs may be seen.USG indicated in patients with PID and 1) palpable mass, 2) severely ill, 3) those failing medical therapy 4) adequate exam unable to be performed.
- 19. Medical Therapy for TOA?Retrospective review of 119 cases of TOA showed a 75% success rate with a trial of medical therapy.When medical therapy not successful, or large abscess is identified, drainage procedures should be employed.
- 20. Transvaginal DrainageLargest study had 302 women, 282 of which were successfully treated with ultrasound-guided aspiration and medical therapy. The sizes of the abscesses in the study ranged from 3 to 15cm.Although 1/3 of patients needed more than one aspiration, only 7% eventually underwent surgery.Size of abscess or multilocularity not importantPatient tolerance was excellentLaparoscopic drainage with concurrent medical therapy is aother option.
- 21. SurgeryAlmost all patients failing to respond within four days require surgery.Closure of the skin and subcutaneous layer is primarily appropriate for those with no free pus in abdomen.
Editor's Notes
- #5: Uterine and adnexal tenderness should be prominent for diagnosis of PID.
- #10: + stain increases probability, - means littleIncreased WBCs is 78% sensitive but only 39% specificIn series of 120 women, probability of PID 11 percent in women with normal WBCs and < or = 3 WBC/hpf from vaginal fluid. No pt with normal ESR had PID.